1881192839 NPI number — VALORIE LYNN LYSTRUP CADC, CPGC-I

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881192839 NPI number — VALORIE LYNN LYSTRUP CADC, CPGC-I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYSTRUP
Provider First Name:
VALORIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CADC, CPGC-I
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881192839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9965 W TROPICAL PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89149-1471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-326-9904
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1681 W HORIZON RIDGE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89012-3494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-476-9700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  00681-C , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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